Periodontal Plastic Surgery
Introduction
The mucogingival relationship is important in sustaining the health of the gingival attachment. Mucogingival surgery is a periodontal surgical procedure used to correct defects in the morphology, position, and/or amount of gingiva.
Gingival augmentation is used in sites with inadequate width and thickness of attached gingiva that exhibit persistent inflammation (bleeding) or progressive recession and sites with inadequate dimensions of gingiva that have subgingival restorations or orthodontics. In sites where crown margins are to be placed subgingivally, recession with exposure of the crown margins may occur when there is inadequate gingival dimensions. Other indications for mucogingival procedures include
(1) elimination of frenum and muscle pull at or near the gingival margin (Figure 24-15),
(2) areas in which the base of a periodontal pocket extends to or beyond the mucogingival junction,
(3) deepening of the buccal vestibule,
(4) aesthetic reasons (e.g., to cover exposed roots), and
(5) modifications of edentulous ridges prior to prosthetic reconstruction.
[Figure 24-15. Frenectomy: (a) Note the lack of attached gingiva on the central incisors and the high frenum attachment that was pulling on the gingival margin. (b) A frenectomy using a split-thickness flap was performed. The frenectomy cuts the frenum, allowing it to relocate further apically. (c) One month postoperative.]
Classification of Gingival Recession
The original classification of gingival recession by Sullivan and Atkins (1985) was later expanded by Miller (1985) (Figure 24-16). The Miller classification includes: I: soft tissue recession not extending to the mucogingival junction; II: isolated soft tissue recession that extends to or beyond the mucogingival junction with intact interdental papillae and no bone loss; III: soft tissue recession extending beyond the mucogingival junction with bone or soft tissue loss in the interdental area and; IV: extensive soft tissue recession and bone loss or soft tissue loss in the interdental area with malpositioned teeth.
Did You Know?
Smokers have less desirable long-term results following periodontal plastic surgery than nonsmokers.
Mucogingival defects are corrected using different types of soft tissue grafts. In addition, guided tissue regeneration procedures also may be used for this purpose.
The pedicle graft, as the name implies, is used to move gingiva from an adjacent tooth or edentulous area to a prepared recipient site on another tooth with an inadequate amount of attached gingiva. The pedicle graft is "freed" on three aspects but retains its attachment (blood supply) from its base. This procedure requires sufficient width and thickness of gingiva to be present in the donor site. There should be no underlying bone dehiscence or fenestration. The pedicle graft is best used for single-site recession for root coverage and augmentation (increasing the amount) of attached gingiva.
Technique (Figure 24-17) A V-shaped incision is made around the recipient site. Incised tissue is removed, and root planing of the root surface is performed. A full- or split-thickness flap is elevated on the tooth away from the defect and rotated to cover the defect. The flap is sutured, and pressure is applied (this is done with all soft tissue grafts) for about 4 to 5 minutes, ensuring that no blood clot has formed under the graft. A periodontal dressing to protect the flap can be placed. If a periodontal dressing is not used, the patient should not brush the area. Postoperative instructions are given to the patient (see Table 24-1), and the patient returns one to two weeks later. At the first postoperative visit, the sutures and the dressing are removed, and the area either may be left uncovered or may be redressed for an additional week.
Table 24-1. Surgical Care Procedures |
| Surgical Procedure | Postoperative Care | Reevaluation Procedures | ||
Gingivectomy | 1. | Instruct patient not to brush the area where the periodontal dressing is located. | 1. | Periodontal probing should not be done until a minimum of six weeks after surgery. |
2. | The area will heal by secondary intention; the wound is open and exposed because there is no flap and no sutures. This area is similar to a scraped knee or pizza burn on the palate. It will be sore. | 2. | Final prosthetic restorations should not be completed until six weeks or more after surgery. | |
3. | Avoid smoking, if possible. | |||
4. | At postoperative visit, carefully remove the dressing, irrigate with sterile water or saline and wipe off the white film (this consists of dead epithelial cells). | |||
5. | Reapply dressing if needed. | 3. | Supragingival scaling can be done after one week, but subgingival periodontal debridement should not be performed until six weeks after surgery. | |
6. | After the first postoperative visit, the patient may start to brush the teeth around the surgical site gently with a roll technique. Bleeding will occur but will gradually lessen. The patient should continue to brush even if light bleeding is seen. | |||
Flap surgery (with or without osseous resection) | 1. | Instruct patient not to brush the area where the periodontal dressing is located. | 1. | Periodontal probing should not be done until a minimum of three months after surgery. |
2. | Apply ice pack. | |||
3. | At postoperative visit, carefully remove the dressing and sutures, irrigate with sterile water or saline and wipe off the white film (this consists of dead epithelial cells). | 2. | Final prosthetic restorations should not be completed until a minimum of three months after surgery. | |
4. | Reapply dressing if needed; patient may start to brush surgical site gently with a roll technique. Bleeding will occur but will gradually lessen. The patient should continue to brush even if bleeding is seen. | 3. | Supragingival scaling can be done after one week, but subgingival periodontal debridement should not be performed until three months after surgery. | |
5. | Avoid smoking, if possible. | |||
Mucogingival surgery (soft tissue grafts) | 1. | Instruct patient not to brush the area where the periodontal dressing is located. | 1. | Gingival grafts with root coverage would be reevaluated a minimum of six months after surgery. |
2. | At postoperative visit, carefully remove the dressing and sutures at the donor site, irrigate with sterile water or saline and wipe off the white film (this consists of dead epithelial cells). | 2. | Gingival grafts without root coverage can be reevaluated a minimum of two months after surgery. | |
3. | Avoid smoking. | |||
4. | Reapply dressing if needed; patient may start to brush surgical site gently with a roll technique. Advise the patient not to hit the gums with the toothbrush. The patient should discontinue brushing if bleeding is seen and only rinse the area with warm water. | |||
Healing Usually, clinical healing occurs in about one month. However, complete maturation can take up to one year.
[Figure 24-17. (a) Lateral incisor with severe gingival recession with root exposure. (b) A laterally positioned flap was used to move gingiva from the right central incisor to the left central incisor. An anchor suture is around the lateral incisor. (c) Two months healing shows good root coverage and increased width of attached gingiva.]
Double Papillae Flap
The double papillae flap is a modification of the laterally positioned flap. The papillae from each side of the tooth with the defect are reflected and rotated over the midfacial aspect of the recipient tooth and sutured.
Unlike a pedicle graft, a free gingival graft (FGG) has a donor site located away from the grafted site. Thus, the blood supply is not attached to the graft but depends on the recipient bed. The most common site for donor tissue is the palate, but in many cases, edentulous areas also can be used. Free gingival grafts are more predictable for augmentation of attached gingiva than for root coverage because significant shrinkage of the graft occurs during healing. Thicker free gingival grafts can be used for root coverage because there is less tissue shrinkage. Often, after a frenectomy a free gingival graft is placed at the site to prevent frenum reattachment.
Technique (Figure 24-18) After local anesthesia is administered on the palate and the recipient area, split-thickness flaps are reflected at the recipient site. A piece of gingiva about 1.5 mm thick is obtained from an intraoral area. Although the most common donor site is the hard palate, edentulous areas also can be used. The donor tissue (graft) is placed on the recipient bed, and the graft is sutured in place, usually with absorbable sutures, making sure that it does not move, since this will interfere with the establishment of a blood supply from the recipient bed and the graft may fail. A periodontal dressing may be applied. Postoperative instructions are given, and the patient returns in one week (see Table 24-1). Smoking is strictly prohibited because soft tissue grafts are more likely to fail if the patient smokes. This was demonstrated by Miller (1987), where he found a 100% correlation between failure to obtain root coverage and heaving smoking. A major disadvantage of free gingival grafts is the poor color match between the graft and the existing gingiva.
Healing The graft will swell initially, then shrinkage occurs (Figure 24-18 d). The graft receives blood and nutrients from the underlying connective tissue. Complete healing with keratinization occurs in about one month.
[Figure 24-18. (a) Mandibular central and right lateral incisors have no attached gingiva (Miller classification III) (b) A free gingival graft was harvested from the palate and (c) sutured into place at the recipient site. (d) Posttreatment healing of the grafted site. Increased width of attached gingiva was achieved. Note that root coverage was not obtained using this type of grafting procedure.]
Subepithelial Connective Tissue Graft
The subepithelial connective tissue graft is the procedure of choice for root coverage of single or multiple teeth. The subepithelial connective tissue graft was first described
by Langer and Calagna (1982) as having several advantages over the other grafts:
(1) There is no open wound on the palate as in a free gingival graft,
(2) the graft has a better blood supply coming from both the underlying connective tissue and the overlaying flap, and
(3) better aesthetics and tissue and color blend are seen.
(1) There is no open wound on the palate as in a free gingival graft,
(2) the graft has a better blood supply coming from both the underlying connective tissue and the overlaying flap, and
(3) better aesthetics and tissue and color blend are seen.
Indications The subepithelial connective tissue graft may be used for both single and multiple adjacent teeth with gingival recession and root exposure (Chambrone & Chambrone, 2006). It is limited by the amount of donor tissue able to be harvested.
Rapid Dental Hint
The free gingival graft donor site will heal by secondary intention (open wound). It may be painful.
Technique (Figures 24-19, 24-20) After local anesthesia is obtained, a split-thickness flap is raised at the recipient site using a surgical blade. A flap is raised at the donor site on the palate, and connective tissue is harvested while leaving the epithelium on the outside of the flap. This palatal flap is sutured into place. The connective tissue is placed on the recipient site and sutured in place with absorbable sutures. A periodontal dressing may be applied. Postoperative instructions are given to the patient, and the patient returns in one to two weeks (see Table 24-1). At one to two weeks, the dressing and
[Figure 24-19. (a) Pretreatment view of the mandibular right central incisor area. There is gingival recession and exposed root surfaces (Miller classification II). A connective tissue graft was selected to cover the root surfaces. (b) The subepithelial connective tissue graft was harvested from the palate. Incisions were made, and the epithelium was reflected. Note the vascular connective tissue underlying the epithelium. (c and d) The graft was sutured to the recipient site and the flap sutured. (e) Flap at donor site is sutured.]
[Figure 24-20. (a) Pretreatment view of the maxillary canine. Miller classification II. Gingival recession occurs beyond the mucogingival junction. The patient complained that the area was sensitive to cold and was not aesthetic. (b) Incisions made on the palate to obtain subepithelial connective tissue. This is the donor site. (c) The connective tissue graft is sutured in placed and then covered by the flap. (d) Healing at two weeks.]
sutures are removed, and the area is either left uncovered or redressed for another week.
Healing Healing occurs through a double blood supply. Both the connective tissue from the recipient site and the overlying flap aid in healing of the soft tissue graft. Complete healing occurs in approximately one month (Figure 24-20 d).
Guided tissue regeneration (GTR) will be discussed further in Chapter 25. Essentially, GTR involves the use of a barrier membrane that is designed to prevent the gingival tissue from establishing contact with the root surface, creating a space for the formation of a new attachment and new bone rather than a long junctional epithelial attachment. This concept was intended originally for the treatment of class II buccal furcation defects and certain infrabony defects. A newer application is for the treatment of gingival recession and for root coverage (Pini Prato et al., 1992).
Alloderm® is a biomaterial that is processed from human tissue. The process removes all epidermal and dermal cells (acellular dermal matrix), while preserving the remaining biological dermal matrix. All cells are removed to remove the risk of rejection or inflammation. This material is indicated for recession defects and for periodontal sites that have little to no attached gingiva where the goal is to increase the amount of keratinized/attached gingiva and to obtain root coverage (Gapski, Parks, & Wang, 2005; Tal, Moses, Zohar, Meir, & Nemcovsky, 2002).
AlloDerm is used in a similar way that a tissue graft from the patient's mouth (e.g., free gingival graft or connective tissue graft) is used except there is no harvesting of donor tissue (e.g., palatal tissue) and thus less pain is involved. At the time of surgery, AlloDerm is rehydrated in sterile saline before it is sutured in place on the recipient bed. AlloDerm acts like a scaffold to support regeneration of the patient's own tissue. Six to eight months postsurgery, AlloDerm becomes integrated into the patient's own soft tissue. A surgical case using AlloDerm is presented in Figure 24-21.
A clinical study showed that treatment with a coronally positioned graft plus AlloDerm significantly increased gingival thickness when compared with a coronally positioned flap alone. Coverage of a recession defect was significantly improved with the use AlloDerm (Woodyard et al., 2004).
Technique After local anesthesia is obtained, a full-thickness flap is raised at the recipient site. Root planing is completed on the root surface. A barrier membrane is placed over the recession and bone and sutured. The flap is positioned coronally covering both the membrane and the enamel. If the membrane is resorbable, it is not removed and will resorb in about six to eight weeks after surgery. The flap sutures are removed after two to four weeks. Patients should not brush the area for at least six weeks and are recommended to rinse with chlorhexidine gluconate.
[Figure 24-21. (a) Preoperative view of the mandibular right quadrant. Note the gingival recession (Miller Classification I). (b) Flap reflected exposing underlying bone. (c) Placement of AlloDerm at recipient site. Flap sutured in place, covering the AlloDerm. (d) Three weeks post-op. Note the root coverage obtained.]
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